Root cause analysis (RCA) is a structured approach to the investigation of patient safety incidents that is commonly applied in many modern health systems worldwide, particularly in acute hospital settings 1 . The RCA technique originated in the engineering industry as a method of identifying latent systems-based issues that contributed to underperformance, variations or design failures in mechanical production processes 2 . Its inherent principles have been adapted in many high reliability organisations – such as the petro-chemical, nuclear power, aerospace and aviation industries – to systematically uncover and improve underlying systems problems, and ergonomic and cultural issues identified as contributory factors in work-related accidents and incidents 3 4 .

In healthcare, safety-based RCA investigations (or variants of this approach) were first introduced in the 1990s to facilitate organisational learning 5 . There is general consensus that RCA utilises a ‘toolbox rather than a single method’ with team-led investigations typically attempting to ascertain the ‘what, how and why’ of identified patient safety incidents 4 . To achieve this, a small multi-disciplinary team of appointed investigators often draws on a multitude of analytical and problem-solving techniques 4 5 6 such as Brainstorming, Pareto Analysis, the Five-Whys technique and Fault-Tree-Analysis to accomplish these aims using recommended step-wise processes (Table 1). Once ‘root causes’ are established by investigators, different levels of local team-based and wider organizational learning needs are determined and a series of improvement recommendations formulated which, if implemented, should minimize the risk of incident recurrence 2 3 4 5 . It should be noted that, broadly speaking, in general medical practice settings particularly in the United Kingdom (UK), significant event analysis (a less rigorous investigative method based on reflective learning theory) rather than RCA is the routinely applied technique of choice for historical and feasibility reasons 7 .

The evidence base underpinning the effectiveness of RCA in healthcare as a method to gain an in-depth understanding of safety issues and facilitate improvements to prevent future incidents is equivocal 9 10 . Controlled trials to test the efficacy of the RCA framework are lacking. Some individual studies of single incident investigations report positive evidence such as the implementation of ‘strong’ corrective actions to prevent recurrence of events as judged by the authors of a recent RCA review in medicine 9 .

However in an evaluation of 445 RCAs undertaken in New South Wales to identify and theme learning needs related to patient, human (staff) and systems factors, the authors concluded that the effectiveness of RCA as a means by which staff can achieve the desired improvements in patient care that were recommended was limited 10 . A recent literature review of RCA effectiveness by Percarpio et al. (2008) identified a small number of formal published studies of relevance 11 . They highlighted ‘numerous theoretical problems with the analytical framework’ and called for more research ‘at the system level and cost-benefits analysis…to determine the effectiveness of RCA’. Additionally, Vincent (2004) describes the RCA methodological approach as ‘misleading’ and suggests that “incident analysis, properly understood, is not a retrospective search for root causes” but should be framed in terms of the incident acting as a ‘window’ on the ‘gaps and inadequacies’ of the healthcare system 6 .

Despite this, it is evident that healthcare authorities and decision-makers have high expectations for the transferability of RCA as an improvement tool, particularly since it seems to be successfully established in non-healthcare industry to investigate safety-critical issues, albeit in arguably more linear and less complex institutional settings 12 13 14 15 . Moreover a range of external healthcare bodies with regulatory, accreditation or quality management oversights expect care provider organisations to have transparent incident reporting and investigation mechanisms in place. In the past decade the National Patient Safety Agency in England and Wales has strongly promoted the adoption of RCA and developed an in-depth training programme and online educational resources to build capacity in this area and support healthcare organisations and staff in explicit efforts to make patient care safer 16 17 .

Similarly in the National Health Service in Scotland (NHSiS) many territorial health authorities have invested heavily in providing internal or external training in RCA methods to a range of staff groups, and this is a cornerstone of their organizational policies for investigating patient safety incidents. However, to our knowledge there has been no systematic attempt to follow-up and evaluate the post-training experiences, benefits and attitudes of NHSiS staff who have received formal instruction in RCA methods, and then put this knowledge into practice in the workplace when required to by their employing organisation. Given this significant investment in people, time and funding, it is important to capture and learn from the reported outcomes of this type of educational intervention, and its subsequent impact in the healthcare system and on improving patient safety.

In this study we aimed to:

1. Measure the extent to which respondents had subsequently participated in formal RCA investigations and also assumed a lead investigator role.

2. Determine the extent to which improvement recommendations arising from RCA investigations were actually implemented.

3. Ascertain if respondents encountered a range of barriers to RCA practice previously cited in the literature.

4. Establish participants’ perceptions of the adequacy of RCA training provided and their attitudes to the value of the tool as an improvement method in the healthcare workplace.

5. Compare relevant aspects of our findings with those reported in a previous Australian study 18 as one way of gauging progress with RCA training and impact in a different setting and at a different point in time.

The main findings provide a measure of the extent to which healthcare staff trained in RCA actually participated in subsequent investigations in the workplace. It is clear in this study that a majority has yet to do so with the greatest proportion of trained but inexperienced staff being based out-with the acute care sector. This is a concern given the resources committed to RCA training and the implications in terms of lost opportunities to improve patient safety and organizational learning, as well as the potentially discouraging impact on staff morale and attitudes. Previous research has reported concerns from RCA-trained staff that they may lack ‘personal control’ over participation in subsequent incident investigations which is likely, for many, to be a decision for local managers in their organisations and heavily dependent upon workload priorities 16 17 18 20 .

The ‘failure of work schedules’ to provide staff with protected time for RCA investigations was cited as the major difficulty by Braithwaite et al. 18 . Edmonson (2004) suggests that leadership has a critical role in this regard in developing an environment of ‘psychological safety’ to encourage a greater willingness for transparency, questioning and sharing of concerns, and also in ‘supporting and empowering’ team learning across the organisation 21 . Nicoloni et al. (2011) also suggest that leaders need to openly endorse RCA (or a variant) as an improvement method and the staff who have been trained to implement it 8 . Without this type of approach then it is possible that local leaders will continue to forfeit opportunities to learn from RCA by occasionally or even frequently assigning a low priority to investigations or blocking participation in the process by trained staff.

Most respondents with RCA experience report multiple exposures to incident investigations. Similar to previous research 9 10 11 16 17 18 19 21 22 , a clear majority also report that their recommendations to make care safer are at least partly or fully implemented in their organisations, although determining how effective these potential improvements actually were was not a study aim but nonetheless should be a subject of further research given the limited evidence.

It is possible, perhaps even likely, that RCA investigators will be subject to some form of ‘criticism’ or ‘conflict’ from ‘powerful’ individuals or groups, or those with vested interests, within a healthcare organisation 22 . It should also be remembered that in essence RCA involves healthcare professionals ‘not just scrutinizing each other but scrutinizing each others’ errors’. Many respondents encountered a range of organizational barriers to conducting RCA investigations similar to those reported previously 18 . A few significant differences were apparent, however, with respondents in our study more likely to adopt a post-training RCA leadership role and also report less difficulty with some of the organizational barriers outlined. One interpretation is that the differences indirectly hint at a slightly more positive organizational safety culture being reported in our study, which is possible given the large-scale national initiatives to improve patient safety in the Scottish health service over recent years 15 . However a more likely explanation is that the Australian study 18 is more than five years older and so associated cultural factors such as the prevailing attitudes and behaviours towards RCA investigations and patient safety in general may have improved over time to match those in our study findings – not that the results reported here offer some type of benchmark.

Similar to other studies, our RCA-experienced respondents were generally positive about the training they received and the cost-benefits of this investigation technique in terms of the ‘advancement of safety in healthcare’ and being a ‘good use of staff time and resources’ 16 18 20 . Respondents displayed mixed views - supported by seemingly logical arguments on both sides - on whether non-clinical colleagues and patients should have a role in incident investigations. However, many risk managers are non-clinical and this does not seem to have been a barrier to them leading on RCA training or advising on, or participating in, related investigations. The involvement of patients and relatives in these investigations is strongly encouraged in national policy 12 13 14 15 , but the reality is that this appears to be a rarity perhaps because of the many sensitivities and difficulties outlined by our respondents, even if many were positive about the prospect.

Most respondents had a sufficient ‘understanding/confidence’ in conducting RCA and indicated that their work practices and reporting of errors have changed since being trained. A follow-up training session and the use of confidential peer feedback on RCA reports were viewed as potentially beneficial educational interventions, suggesting that many respondents may have a level of insight into the need for further learning around the often complex and problematic issues involved in applying the technique. The inconsistent quality of RCA attempts and the need for additional post-training support has been noted previously 17 19 . The study by Wallace et al. (2009) reports high levels of satisfaction with RCA training, but low levels of correct responses when study participants were subsequently tested on their acquired knowledge of RCA using pre-designed vignettes 16 .

Overall the evidence demonstrates that the standard of incident analysis and report writing is frequently variable 7 16 17 19 . Given that the written report is a key proxy for the quality of the investigation undertaken then it is likely that some type of educational feedback intervention is necessary. Offering developmental support and mentorship, particularly to guide less experienced staff confronting and dealing with some of the aforementioned barriers to RCA, and when writing comprehensive unambiguous reports that offer realistic recommendations for improvement (either during training or after training or both), arguably makes sense in closing this educational gap. Taken together the combined evidence from this and other studies cited may point to an organisational learning need for continuous development and feedback for RCA-trained staff, or at least in the short-term 7 16 18 20 .

The study findings are not generalisable beyond the RCA training practices in this single health authority. But given the degree of congruence with Braithwaite et al. 18 and specific findings in previous research 9 10 11 16 17 19 21 22 , it is possible that similar issues would be uncovered in other regions and countries with comparable training arrangements, particularly with regard to the significant proportion of trained staff who do not gain any post-training investigation experience. A key consideration, therefore, will be the cost-benefits involved in taking healthcare staff out of frontline clinical duties to provide them with RCA training and then failing to utilize or support them in the post-training phase.

One potential option is to better select staff for more intensive RCA training, while training less staff numbers so that organisations develop a strong core grouping with the requisite experience, expertise and leadership skills - augmented by the provision of continuous developmental support. Potentially this offers a number of advantages over current arrangements. A better trained and dedicated RCA staff group which is afforded greater opportunities to gain experience may retain and strengthen their analytical knowledge and skills and also benefit from shared peer-to-peer learning – leading to more meaningful and effective incident investigations. In developing this ‘expert community of practice’, these individuals (or as a group) may also become better equipped to highlight and challenge existing institutional barriers to engaging in and learning from incident investigation and start to make progress in developing a more positive safety culture. However, this will require organisations – and, perhaps more specifically, local healthcare leaders - to give greater priority to investigations and provide some element of protected time for these staff to continue to develop related experience and expertise when necessary. In some cases this may require a paradigm shift in local middle management and executive level attitudes and behaviours towards improving patient safety that goes beyond purely rhetorical endorsement of this concept as the single most important healthcare priority. A recent high profile media exposure of inconsistencies around serious patient safety incident investigation practices across NHSiS may have some impact in this regard 23 .

The study quantified some important problems within a single NHS board’s RCA training programme which will be of wider interest in Scotland and internationally. This adds to our knowledge and understanding of the need to improve the effectiveness of related training and frontline practices in healthcare settings. There is an assumption that organizations can train staff in RCA and learn from associated outcomes as if it is a linear, “rational, robust and rigorous process” 8 22 . However, healthcare authorities may wish to look more critically at the system and cultural complexities which impact RCA investigations; the professional groupings and numbers of staff whom they select to attend training; and how these programmes are delivered and supported educationally in the longer term to maximize cost-benefits, organizational learning and safer patient care. A deeper understanding of the socio-cultural issues at play is also necessary, but this will require a policy commitment to resource more in-depth social research and evaluation, particularly if developing, testing and implementing new training paradigms.

The authors declare there are no competing financial or non-financial interests.

PB conceived the study idea, acquired funding, co-led the study design, data collection, analysis and interpretation, and drafted the initial manuscript. JS co-led the study design and data collection, and contributed to the content and critical review of the manuscript. CdW led on the statistical analysis and interpretation, and contributed to the content and critical review of the manuscript. All authors read and approved the final manuscript.